Australasian Emergency Nursing Journal (2008) 11, 135—144

available at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/aenj

LITERATURE REVIEW

Are nurses ready?

Disaster preparedness in the acute setting
Kija Chapman, BHSc, BN, RN ∗
Paul Arbon, AM, BSc, DipEd, GradDipHealthEd, MEdStudies, PhD

School of Nursing & Midwifery, Flinders University, Sturt Road, Bedford Park, SA 5042, Australia

Received 3 January 2008; received in revised form 12 March 2008; accepted 9 April 2008

KEYWORDS Summary
Disasters; Background: The impact of disasters is believed to be increasing internationally, and nurses
Disaster planning; are more likely to be confronted with a need to provide nursing care to victims affected by
Disaster medicine; disaster. The evidence-base of disaster health in the acute setting is very limited, both in
Mass casualty event; Australia and internationally. This review identifies key themes and issues identified in recent
Emergency nursing; disaster healthcare research literature.
Nursing education Methods: Sixteen research articles were reviewed. A number of Flinders University Library
databases were searched for relevant articles. Reference lists of original papers and grey liter-
ature were searched for additional research papers, and availability followed up on the Flinders
University online library of journals.
Results: Four major themes that most frequently featured in disaster health research were iden-
tified. These included nurse education in disaster response; nurse (including students) issues,
concerns, attitudes and perceived preparedness for disaster response; disaster planning in acute
settings; and surge capacities of acute settings.
Conclusions: Disaster events, both natural and man-made have become of increasing concern
to health care workers, particularly nurses, in recent years. Research highlights that education
in disaster response, disaster plans and surge capacity are generally not well implemented or
standardised in the acute setting. While research identifies gaps in disaster preparedness in
Australian and international acute settings, it is difficult to make clear recommendations for
improvement without further, more focussed research.
Crown Copyright © 2008 Published by Elsevier Ltd on behalf of College of Emergency Nursing
Australasia Ltd. All rights reserved.

∗ Corresponding author at: 9 Wilpena Terrace, Kilkenny, SA 5009, Australia. Tel.: +61 411778503.
E-mail address: [email protected] (K. Chapman).

1574-6267/$ — see front matter. Crown Copyright © 2008 Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia Ltd. All rights reserved.
doi:10.1016/j.aenj.2008.04.002
136 K. Chapman, P. Arbon

Background component of disaster training for all health care workers

(including students) should be considered, as this presently
Definition of disaster doesn’t exist.3,5,8,11,13,15,19,20,24

Disaster has been defined as ‘‘. . .a situation where people’s Education

normal means of support for life with dignity have failed
as a result of natural or man-made catastrophe,’’14 and Training and education are long accepted by researchers
‘‘. . .whose destructive impact overwhelms a community’s in disaster response as an essential part of preparedness.11
ability to meet healthcare demands.’’10 Disaster nursing is While no hospital can be completely prepared or resourced
defined by the Society of Disaster Nursing as ‘‘. . .the system- in the event of a mass casualty incident, at present many
atic and flexible utilization of knowledge and skills specific Australian and international hospitals and staff would be
to disaster-related nursing, and the promotion of a wide unlikely to cope with any more than small numbers of seri-
range of activities to minimise the health hazards and life ously injured patients.3,5,7,24,25 There are no currently taught
threatening damage caused by disaster in collaboration with practices or competencies in disaster health response that
other specialized fields.’’15 are strongly evidence-based, widely accepted and thought
to be essential in training of all health care staff.10
Nurse involvement
Nurses’ roles
While nurses may be willing to respond to a disaster
event, the actual response may be determined by the Disasters occurring in urban areas are characterised by about
nurse’s sense of clinical competence, perception of personal 50—80% of the casualties making their own way to hospital in
safety and the confidence of safety of family and signifi- search of medical attention within 1—1.5 h of the event.3,5,24
cant others.6,11,14,17,18 For example, nurses responding to an Frequently the evacuation by emergency services of the
overseas disaster are required to work in ‘‘. . .difficult, disor- most seriously injured to surrounding hospitals also occurs
ganised and poorly resourced situations. . .’’1 , Furthermore, within this short time frame. These two features of typical
nurses are frequently required to work outside of their scope urban disasters combine to place great stress on acute hos-
of practice in disaster response, including carrying out unfa- pitals which receive a surge of patients. Staff are required to
miliar procedures for patients with injuries rarely seen in take on extended roles and many hospital in patients must
usual practice.1,3,7,24 be rapidly discharged to make room for casualties. While
nurses may not directly determine which patients are dis-
Preparation charged and when from the acute setting, nurses do have
a role in knowing patients and their presenting conditions,
It has been found that few nurses give consideration to moving approved patients to other areas of the acute setting
practical preparation and experience required to deploy or into the community, allocating sufficient nursing staff to
in response to a disaster event.1 Even in unexpected sit- manage patient loads at all times, triage of patients pre-
uations such as disasters, nurses should be aware of their senting at emergency departments and ordering of stocks
limitations, including skills, knowledge, ability, authority, from hospital pharmacies, to name a few.4,9,16
expected role in the mass casualty incident and equipment This paper examines recent disaster health research lit-
they might require to provide care.7,13,14 Furthermore, the erature and identifies key themes and issues for nursing
national nursing shortage in Australia could impact on the preparedness, including skills and available resources for
ability of the Australian health care system to provide safe disaster response in the acute setting. These themes and
care to patients if large numbers of nurses are deployed issues are drawn from international sources and as such
overseas in response to a disaster event.1,3 are influenced by varying health systems, disaster types
or threats and different standards and approaches to the
education of health professionals and to patient care. Con-
Disaster impact sequently the review is not intended as a critique of disaster
preparedness in any one health system or hospital. Nonethe-
The impact of disasters is also believed to be increasing less, these key themes and issues should be taken into
internationally, and nurses are more likely to be confronted account, acted upon or, alternately, discounted in the pro-
with a need to provide nursing care to victims affected cess of risk analysis and preparation in Australian hospitals.
by disaster.1 In light of this, issues have been raised about
the current level of education, specialty, immunisation sta-
tus and experience in nursing disaster preparedness.1 While Methods
all Australian states and territories have disaster plans
in place, it is believed that State and Federal agencies This review included recent research literature concerning
need to review and gather current expert advice in order the role and issues for nurses and acute hospital systems
to improve Australia’s level of disaster health prepared- exposed to a disaster event.
ness and develop new educational opportunities in disaster A total of 16 articles were included for integra-
nursing.1,3,24 It has been suggested that disaster prepared- tive review.1,2,4,6,8,9,15—17,19,20,22,26—29 A number of literature
ness practices in countries where terrorist attacks occur searches were conducted between May and September,
frequently (i.e. Israel) and development of a mandatory 2007 using Flinders University online library of databases
Disaster preparedness in the acute setting 137

Table 1 Summary of primary research

Authors, year Sample #, population Level of evidence

Arbon et al., 2006 1

• 3683 calls from nurses offering assistance • Level III-3 retrospective cohort study21
following 2004 Indian Ocean earthquake and
tsunami
Bartley et al., 20062 • 50 senior staff from Geelong Hospital, • Qualitative level IV pre/post-test
Victoria case series from 1 Victorian hospital21
• 360-bed hospital and houses the sole ED for
catchment population of 250,000 people
• 42% ED staff, 58% non-ED staff
Davis et al., 20054 • 82 nurse mangers from 4 San Diego hospitals • Level IV cross-sectional study21
and 25 physicians from two academic centers
• Bed capacities between 120—372
• 1 Level I trauma hospital, 2 Level II trauma
hospitals and 1 non-trauma hospital
French et al., 20026 • Convenience sample of 30 emergency • Qualitative level IV cross-sectional
department nurses focus study using convenience
• 4 Florida community hospitals involved — 1 a sampling21
level II trauma centre
Greenberg et al., 20028 • 54 physician directors of hospital ED’s in the • Qualitative level IV cross-sectional
greater Philadelphia area — 88.5% response study21
rate
Hirshberg et al., 20059 • Simulated casualties based on 223 patients • Level III-3 interrupted time series
from 22 bombing incidents over 3 years treated without parallel control group21
at a 1200 bed Israeli regional trauma centre
• 42 randomly selected, critically injured
patients and 19 mildly injured patients
over-triaged to shock room during 6 month
period
• Staff availability data from anonymous audit
conducted on 15 consecutive days
Jennings-Sanders et al., 200515 • Convenience sampling to recruit 51 • Qualitative, descriptive level IV
senior-year nursing students in a community cross-sectional study21
health nursing class
• 88% working in health care setting, 59%
would be working in medical-surgical setting
after graduation
Kaji and Lewis, 200616 • Convenience sample of first 45 designated • Qualitative level IV cross-sectional
9-1-1 receiving hospitals in Los Angeles County study21
to respond to authors invitation of
participation
Mitani et al., 200317 • 457 nurses in 4 Japanese hospitals • Qualitative level III-3 historical
• 65.4% respondents qualified nurses, 34.6% control study21
nursing students
Murray et al., 200619 • Series of 4 meetings of the Working Group of • Pilot qualitative, descriptive level III-3
the Education Committee of the WADEM, with retrospective cohort study21
50 representatives from 18 countries — 45
involved in disaster health education and
training
Nasrabadi et al., 200720 • 13 RN’s with bachelor’s degree in nursing • Level IV post-test case series21
• At least 2 weeks experience as RN’s during
the Bam disaster in the earthquake location
Riba and Reches, 200222 • 60 nurses from 4 hospitals (small & large • Qualitative level IV cross-sectional
sized) in Israel, all with certification in study21
intensive care or emergency nursing
• Nurses from ‘‘. . .cities that underwent
multi-casualty terrorist attacks. . .’’ invited to
participate in the study
138 K. Chapman, P. Arbon

Table 1 (Continued )

Authors, year Sample #, population Level of evidence

Traub et al., 2007 26

• 88 (94% response rate) Emergency • Level IV cross-sectional study21
Department Directors of Australasian College
for Emergency Medicine (ACEM), and 7 (100%
response rate) private and non-ACEM
accredited ED’s staffed by ACEM Fellows in
metropolital Sydney
Tur-Kaspa et al., 199927 • 21 major Israeli hospitals • Level III-3 interrupted time series
• 30 chemical drills between 1986—1994 with without parallel control group21
100—400 simulated patients in each drill
Weiner et al., 200528 • 2013 Deans or Directors of nursing schools in • Level IV cross-sectional study21
348 schools of nursing in the US
Wetta-Hall et al., 200629 • 15 nurses, all female • Level IV pre/post-test case series21
• Majority 40 years and older
• Majority practiced nursing for over 20 years

Aust Health, Blackwell-Synergy, CINAHL, ProQuest and Wiley Nurse education and experience in disaster
Interscience. The website for the journal Prehospital and response
Disaster Medicine was also utilised and explored for relevant
articles. Keywords in searches included nursing prepared- Preparation of nurses related to the level of training
ness for disaster (357 total hits); mass casualty event received, either in the acute setting or educational insti-
(674 total hits); emergency preparedness (2,365 total hits); tutions, as well as experience through participation in a
emergency nursing (7,966 total hits); disaster response disaster response. Eight studies focussed on nursing edu-
(7,227 total hits); disaster preparedness (1,309 total hits); cation and experience in disaster response.1,2,6,15,19,20,27,28
disaster medicine (3,257 total hits); nursing education One study found that more than 80% of nurses volunteering
(25,653 total hits); disasters (14,138 total hits); and dis- for a disaster event had no previous experience in disaster
aster epidemiology (749 total hits). Article titles were response.1
searched for inclusion of keywords. Reference lists of all When pre and post-intervention studies were conducted,
original papers and grey literature were also searched for findings indicated that knowledge of senior nurses for
additional sources that could be included, and availabil- disaster response improved, with one study reporting a
ity followed up on the Flinders University online library of pre-intervention pass rate of 18% vs a post-intervention
journals. pass rate of 50%.2 Improved disaster response ability post-
Potential articles underwent title, abstract and full education was reported, although no data was provided
review for eligibility, and were excluded from the review regarding pre and post-testing results.27 Education was pro-
if they did not meet specific criteria: less than 10 years old, vided in disaster preparedness at many hospitals, although
primary research, included data on nursing staff/students, it varied between the institutions, and was not described
not pre-hospital disaster response focussed, and available in the study.6 It was also found that 23% of partici-
in English and full-text. Both Australian and international pants surveyed reported only receiving initial education;
research was reviewed to compare disaster preparedness of 29% received only continuing professional development,
nurses in a variety of acute settings. 77 potentially relevant and 48% received both.19 Furthermore, 39% of teaching
articles were identified for use in the literature review. Of occurred occasionally, 13% annually, 13% biannually, and 19%
these, 61 were ineligible for inclusion. triannually.19 In addition, 65% of courses were accredited to
Four major themes were identified, based upon those some degree, with 23% locally accredited; 58% nationally;
that featured most frequently in reviewed research: and 13% internationally.19 100% of education provided was in
nurse (including students) education and experience the student’s native language or the most commonly spoken
in disaster response; nurse (including students) issues, language of the country where education occurred.19
concerns and attitudes surrounding disaster response, In the 2000—2001 academic year, 32.7% of US nursing
including perceived preparedness for disaster; disaster schools offered some content in disaster preparedness.28 By
planning in acute settings; and surge capacity of acute the 2002—2003 year (following the September 11 terrorist
settings. attack on the World Trade Centre in New York), this had
increased to 53%.28 Nursing students asked to give a def-
inition of disaster nursing had varied responses, outlined
Results in Table 2.15 Table 3 shows areas nursing students suggest
should be included in disaster nursing curricula, and Table 4
Table 1 briefly summarises the 16 reviewed primary research displays nursing specialties nursing students believe to play
articles. Information includes author list and year of publi- a significant role in disaster response.15 Finally, of partici-
cation, sample population, and NHMRC level of evidence.21 pants surveyed, 92% believed that disaster nursing should be
Disaster preparedness in the acute setting 139

Table 2 Definition of disaster nursing Table 6 Resources used to supplement course content in
disaster preparedness

average percentage of contact hours dedicated to disaster

preparedness education was 4%, and 74% of the nursing fac-
Table 3 Suggested disaster nursing curriculum content
ulty believed they were poorly prepared to teach disaster
preparedness to nursing students.28 No results were pro-
vided in any reviewed studies relating to preferred or most
effective methods of information delivery.

Nurse (including students) issues, concerns and

attitudes surrounding disaster response, including
perceived preparedness for disaster

Six reviewed articles had some focus on nursing issues, con-

cerns, attitudes and or perceived disaster preparedness in
incorporated into the nursing curriculum; 64% believed that the acute setting.2,6,17,20,22,29 One study compared perceived
their area was not immune to a terrorist attack or disas- personal and departmental preparedness for disaster and
ter incident; 21% believed that there was a need to prepare importance of disaster preparedness in the department.2
for disaster events; 11% believed that disaster preparedness The results of this study are shown in Table 7.2 This high-
training should be provided in a community nursing course; lights the need for a multi-disciplinary approach in disaster
4% believed that disaster preparedness education helps to planning and preparedness, as personal preparedness alone
teach nursing students about other career paths.15 Only 2% does not ensure the smooth running of an entire department
believed that there was already too much in the curricu- or hospital in a disaster response incident.20
lum and that disaster preparedness education should not be One study reported that participant’s primary concerns
taught.15 in disaster response included safety of family members, pet
There are a variety of reported methods of disaster care and personal safety at work.6 These factors potentially
education available, outlined in Table 5.19 Another study influence nursing response to a disaster incident, although
reported resources used to supplement course content in actual figures were not reported. In contrast, it was found
disaster preparedness education, outlined in Table 6.28 The that nurses surveyed felt initial reactions to news of a dis-
aster event that included a deep sense of commitment,
empowerment and need to respond to the event, regardless
Table 4 Nursing specialties believed significant in disaster
of what they were doing prior and what complexities may
response
arise in making preparations for their families.22 It was also
reported that motivation for attending training sessions on
disaster preparedness was personal and professional, where
nurses felt that they had a responsibility to be trained and
prepared for a disaster event.29
In contrast, nurses had a number of reasons for not par-
ticipating in disaster response following the 1995 Great
Hanshin-Awaji Earthquake in Japan, generally related to

Table 7 Pre-intervention post-intervention

Table 5 Methods of presenting disaster information (%)

140 K. Chapman, P. Arbon

the 2004 Indian Ocean earthquake and tsunami, even though

Table 8 Reasons to not participate in 1995 Great Hanshin-
they were not adequately prepared for what they may face
Awaji Earthquake
in responding to a disaster event.1

Disaster planning in acute settings

Five reviewed articles addressed disaster planning in the

acute setting.1,6,8,16,27 Disaster planning included whether
adequate resources, personal and professional, are avail-
able to nursing staff in preparing for and following a disaster
event. Findings indicate that 66.7—96% of responding hos-
pitals had some degree of written disaster plan.8,16 Various
hospital disaster plans studied discussed guidelines, out-
perceived professional ability, or the disaster incident
lined in Table 11.6,8,16 However, only 29% of studied hospitals
itself.17 These are included in Table 8.17 However, another
had immediate access to more than 6 ventilators; 42% had
study reported that with experience and familiarity with
warm-water decontamination; 51% had chemical antidote
procedures and protocols in disaster response, nurses sur-
stockpiles; and 42% had antibiotic stockpiles.16 Another
veyed reported that fears of inadequacy were replaced with
study found that no hospitals surveyed included food, water,
knowledge that response to a multi casualty event requires
sleeping or uniform provisions in the event of a disaster.6
the same skills as other nursing situations.22 The importance
It was also reported that 9.3% of staff surveyed in one
of nurse leaders in reducing anxiety was also reported.22
study didn’t know if a disaster plan existed.8 Further-
Furthermore, 84.2% of nurses would be prepared to
more, less than 2% of surveyed emergency departments
respond to a disaster incident if certain conditions were
met minimum disaster preparedness requirements, only
met.17 Only 6.3% would participate in future disaster events
10.5% of participants had previously participated in disaster
without conditions, and 9.5% would not respond to any
preparedness training, and 59.3% reported having not par-
disaster.17 Conditions of participation reported are included
ticipated in a biochemical disaster exercise in the last 12
in Table 9.17 In addition, information considered essential
months.8 In addition, 83.5% of nurses volunteering their ser-
to know prior to disaster response included the scale and
vices to disaster response had no relevant language skills for
damage of disaster (89.1%); the site of disaster and terms
an overseas response; 39% were unsure of their immunisa-
of dispatch (63.5%); contents of work and status in response
tion status and 59.9% were only able to make themselves
(43.4%); availability of transportation (40.9%); and the situ-
available for response for a short time period.1 Finally,
ation of electricity/gas/water supply (40.3%).17
one study found that no staff received standard debrief-
Finally, nurses believed an essential knowledge base for
ing sessions following a disaster event, although debriefing
disaster response was essential, with the most commonly
is considered an essential part of disaster planning and
expressed knowledge base presented in Table 10.17 This is in
response.6,22
contrast to Australian nurses, who were willing to respond to

Surge capacities of acute settings

Table 9 Conditions of participation in disaster response
Of sixteen articles reviewed, four focussed on surge
capacity, or the ability to cope with increased numbers
of casualties, in the acute setting following a disaster
incident.4,9,16,26
Findings indicate that hospitals in Australia and inter-
nationally have limited surge capacity, although there are
systems in place to discharge certain existing inpatients in

Table 11 Disaster plan guidelines

Table 10 Essential knowledge base of nurses involved in
disaster response
Disaster preparedness in the acute setting 141

also in a good position to be able to detect changes in normal

Table 12 Surge capacity 72 h post disaster event
health and illness patterns that may require a large scale
announcement
emergency response.7 Believing that they are adequately
prepared for a disaster event may empower nurses and
increase their confidence in response, while inexperience
may contribute to stress and fear of disaster response.7,22
Therefore, nurses need to know that they are supported
during disaster response, and are more likely to participate
if they have some information about the event, direction
in their practice during response, adequate knowledge in
what to possibly expect, how to respond to injuries that
*ICU: intensive care unit, LLC: lower level care, ICP: intermedi-
may be seen, assurance of safety for both themselves and
ate care patients. family members, and the opportunity to debrief following
the event.6,17,20,22
A number of disaster education programs have been
the acute setting when a disaster event strikes. An example developed (for example Major Incident Medical Management
is displayed in Table 12.4 Another study found that 29% of and Support, see http://www.alsg.org/index.php?id=14,
hospitals studied had a surge capacity of less than 20 beds and Incident Command System, see
and 60% of the hospitals studied were on diversion more than http://training.fema.gov/EMIWeb/IS/is100.asp), although
20% of the time under normal circumstances.16 these have not been validated or incorporated into standard
Over-triage of patients can have an affect on the surge international healthcare professional training, nor are they
capacity of trauma assets of a hospital of between 50—75% necessarily explicit to disaster nursing education.7,11 There
or more.9 At this level, only 58% of health care worker time are also limited publicly available studies on the use of
is spent on treating critical casualties, vs 92% when over- disaster drills to train nurses in disaster response, and there-
triage is at 25%.9 Furthermore, when full trauma assets are fore a limited ability to implement standards in effective
deployed in response to a disaster event, one study found disaster preparedness at present, particularly in the areas
that there is a gradual decline in the level of care provided to of chemical, biological and radiological hazards.3,5,10,18,19
victims.9 Specifically, 10.8 critical patients/hour presenting Therefore, it has been difficult to establish the effective-
for treatment were seen when only immediately available ness of hospital disaster drills due to limited objective data,
staff and resources were utilised in response to a disas- which tends not to include pre and post knowledge scores
ter event, and 14.4 critical patients/hour when sufficient or statistics that may indicate significant improvement.
warning was assumed to deploy all hospital trauma assets, Having said this, 2 studies reviewed did this to some
including staff called from home.9 degree, and found that knowledge and confidence did
Another study found that 61—82% of critically injured improve among healthcare workers exposed to disaster
patients in Australian and New Zealand hospitals surveyed education.2,27 However, neither study assessed the effec-
would not have immediate access to operative care; 34—70% tiveness of disaster education using a control group of health
would have delayed access to ICU beds; and 42% of less criti- care workers who receive no disaster education against a
cally injured patients would have delayed access to medical group receiving intervention at varying levels. Perhaps this
imaging facilities, such as X-ray.26 It was found that the best- is an area that could be explored in future research, and
case scenario involved critically injured patients occupying could incorporate the effectiveness of disaster education at
all but 19% of ICU beds following a disaster incident, assum- varying levels, such as only receiving lecture based disaster
ing that they weren’t already occupied.26 This means that education compared to receiving lecture based education
at any given time, over 80% of ICU beds would need to be along with engaging in a disaster drill or simulation event.
cleared if a disaster event were to occur. It was suggested While disasters are unpredictable in nature and not a rou-
that perhaps ICU beds could be cleared to 15% following tine occurrence, it is perhaps impossible to pre-determine
a disaster incident where the hospital engages discharge of injuries that may be seen, numbers of victims, and type
present patients to clear room for disaster victims, although of disaster event.7,11 However, nurses can be pre-equipped
it would be interesting to see if this were possible in an and confident in their ability to respond to disaster events
actual or simulated event.4 through having a standardised, organised, regularly eval-
uated disaster plan in place in the acute setting with
Discussion regular, formal, evidence-based education.7,11 It is believed
that nurses in all settings must be prepared to respond to
The reviewed research highlights that gaps exist in disas- external and internal disasters as effectively as possible,
ter preparedness of nurses in the acute setting, suggesting and should be encouraged to promote disaster prepared-
a shortage in both nursing skills and resources to respond ness in their daily routine.3,5,9,14,19,20,27,29 Positive outcomes
effectively to disasters. of nursing disaster education may include improved staff
Early response to a disaster event may minimise damage confidence and understanding of disaster plans and equip-
caused by the event, but critical response by healthcare ment, improved patient tracking and flow, decreased victim
workers requires that there is the knowledge and ability mortality rates, improved health status and decreased
to respond to often unknown situations, make quick and disaster-related costs.10,14 Furthermore, disaster education
effective decisions, and protect the facility and resources.11 can identify deficiencies and areas for improvement in
Because of their extensive contact with patients, nurses are terms of decision-making processes; information systems;
142 K. Chapman, P. Arbon

clinical operation by inexperienced staff; errors in treat- related deaths in Australia, although the recommended level
ment, triage and documentation; inadequate training; and is below 10%.3 If these figures exist during ‘‘normal’’ circum-
resource shortages.5,10,12 stances, it is difficult to see how the hospital system would
Therefore, it is believed that implementation of min- cope with a sudden mass casualty event.
imum national standards in disaster preparedness could
improve hospital and health care professional’s (particu- Limitations
larly nurses) knowledge and ability to plan and respond to
disasters appropriately, and guide planning exercises and
Most papers reviewed were qualitative and based on expe-
establish surge capacities so that hospital’s are aware of
riences and opinions, rather than quantitative response
patient loads they could handle in a mass casualty event.3,11
to disaster.1,2,6,8,15—17,19—23,28,29 Quantitative papers included
An integrated response is considered very important, and
generally related to surge capacities of hospitals in the
training should be ‘‘cross-cutting,’’ with competencies
event of a mass casualty event, rather than education,
specified and inclusive of the multi-disciplinary nature of
skills or training that could be implemented to improve dis-
disaster preparedness and response.11
aster preparedness of nurses in the acute setting.4,9,26,27
Suggested areas of disaster education include training
It is difficult to draw valid conclusions without use of an
staff in major incident management, including crowd con-
experimental control group, random assignment of groups
trol and hospital security; set up of operational or control
to experimental and control groups, and control of an inde-
units; nomination of key personnel; efficient intra-hospital
pendent variable.21,23 In reality, a disaster situation may be
communication; enhanced links with other emergency ser-
different to practiced drills and education, and a level of
vices and hospitals; set up of media management and public
uncertainty will therefore always exist in disaster response.
information centres; availability of stress management and
Furthermore, in disaster preparedness research, it would
counseling services for health care staff, victims, rela-
be difficult to determine ‘‘control’’ and ‘‘experimental’’
tives and communities following a mass casualty incident;
groups, as all persons involved would have some role in
training in containment and decontamination, including cor-
the response, either as a responder, victim, or other role.
rect use of personal protective equipment; careful triage
Given this, perhaps consideration of literature surrounding
and initiation of physical assessment and interventions;
disaster preparedness should include comparisons of findings
adequate resource stocks (i.e. antidotes, medications,
across all areas of disaster preparedness research and expert
ventilators, staff uniforms, sleeping provisions, food,
opinion to determine potential ‘‘best’’ practice in disas-
etc.); and planning for long-term rehabilitation needs of
ter preparedness, with implementation of common findings.
victims.3,5,8,9,10,11—13,16,18,20,24,29 However, cost-effectiveness
Constant re-evaluation of new research and results of imple-
of disaster preparedness education and training is not well
mentation of findings in practice can also help to ensure that
established, and commitment of resources by employers and
‘‘best’’ practice in disaster preparedness moves forward
Governments is therefore limited.5,10,12,18 Perhaps research
with the current climate.
looking into the cost and effectiveness of various disaster
Other limitations in this paper include the relatively small
preparedness education programs would identify key areas
number of papers reviewed and lack of research specifi-
that could attract employer and Government support?
cally related to disaster preparedness of nurses in the acute
It is believed that the optimum way to test disaster
setting. Many papers looked at medical response to disas-
preparedness systems is by linking theoretical knowledge
ters or pre-hospital disaster response, and were not specific
and education in disaster management to unannounced,
to nurses.2,4,8,9,16,19,26—28 While a multi-disciplinary response
simulated or ‘‘tabletop’’ exercises and ‘‘real-time’’ drills
to disaster preparedness in the acute setting is considered
with staff using ‘‘. . .moulaged casualties’’ and ‘‘smart simu-
essential, more research is required into the specific role
lated victims.’’3,5,13,14,24 At least yearly, but preferably twice
of nurses in disaster response in the acute setting, and how
yearly emergency management plan testing is recommended
nurses can best be educated and trained to fulfill this role.
using at least one community-wide practice drill and one
In addition, it should be noted that each research paper
drill using simulated or volunteer participants.3,5,10,29 While
focussed on a particular health setting and context and the
these types of disaster preparedness drills do exist in emer-
relative level of external validity of the findings of individ-
gency services, they often don’t involve hospitals, either as
ual research needs to be considered. Nonetheless, existing
part of State Disaster Plans or in isolation.24 Some countries
research does provide information about lessons that may
participate in regular exercises or drills that focus on mass
need to be learned in our own health setting.
casualty management, which are found to be effective in
training hospital staff in disaster response.10,24
Finally, it is essential to build sufficient surge capac- Conclusions
ity into major trauma centres.3,24 Intensive care, operating
theatres, medical imaging areas, and wards require suffi- Disaster events, both natural and man-made have become
cient clearing of present patients to accommodate victims of increasing concern to health care workers and the public
of a mass casualty incident and improve the hospital’s in recent years. To add to this concern, research highlights
surge capacity.3,4,12,24 It is also critical that experienced that education in disaster response, disaster plans and surge
and adequately trained staff perform triage and frequent capacity are not well implemented in the acute setting,
reassessment of casualties in emergency departments to and not standardised. However, research also indicates that
create a unidirectional flow of casualties and detect any ini- education, effective disaster planning and improved surge
tially missed injuries.24 At present, overcrowded emergency capacity in the acute setting can be beneficial in improv-
departments contribute up to 30% of preventable trauma ing the confidence, knowledge and clinical skills of nurses,
Disaster preparedness in the acute setting 143

and improve communication and coordination of the hospital 3. Bergin A, Khosa B. Are we ready? Healthcare preparedness for
system in anticipation and response to disaster events. catastrophic terrorism. Australian Strategic Policy Institute
The purpose of this literature review was to identify 2007(4):1—19. Available at: www.aspi.org.au/publications/
research examining nursing preparedness for disaster in publications all.aspx. Accessed 28/8/07.
the acute setting. While research identifies gaps in nurs- 4. Davis DP, Poste JC, Hicks T, Polk D, Rymer TE, Jacoby I. Hospital
bed surge capacity in the event of a mass-casualty incident.
ing education in disaster preparedness, disaster plans and
Prehosp Disast Med 2005;20(3):169—76.
surge capacities in international acute settings, it is diffi- 5. Edwards NA, Caldicott DGE, Eliseo T, Pearce A. Truth hurts
cult to make clear recommendations in these areas based — hard lessons learned from Australia’s largest mass casu-
on research findings. A variety of research designs featured alty exercise with contaminated patients. Emerg Med Aust
in the integrative review of articles, and research was not 2006;18:185—95.
considered scientifically rigorous for any article reviewed. 6. French ED, Sole ML, Byers JF. A comparison of nurses’
This makes implementation in the clinical setting difficult needs/concerns and hospital disaster plans following Florida’s
to establish. Hurricane Floyd. J Emerg Nurs 2002;28(2):111—7.
While recommendations have widely been made that 7. Gebbie KM, Qureshi K. Emergency and disaster preparedness.
disaster education and hospital disaster plans should be Am J Nurs 2002;102(1):46—51.
8. Greenberg MI, Jurgens SM, Gracely EJ. Emergency depart-
standardised, without establishment of the ‘‘best’’ methods
ment preparedness for the evaluation and treatment of victims
of disaster preparedness implementation in the research, of biological or chemical terrorist attack. J Emerg Med
this standardisation can not occur. Financial support by 2002;22(3):273—8.
employers and Government to date has not been given due 9. Hirshberg A, Scott BG, Granchi T, Wall MJ, Mattox KL, Stein M.
to a lack of scientifically proven methods in disaster educa- How does casualty load affect trauma care in urban bombing
tion and disaster planning. Furthermore, political and other incidents? A quantitative analysis. J Trauma, Injury, Infect Crit
influences (i.e. media) may influence funding in areas of dis- Care 2005;58:686—95.
aster preparedness, depending on the current climate. This 10. Hsu EB, Jenckes MW, Catlett CL, Robinson KA, Feuerstein C,
may mean that few hospital settings can engage in disaster Cosgrove SE, et al. Effectiveness of hospital staff mass-casualty
education, and health care workers and hospital systems incident training methods: a systematic literature review. Pre-
hosp Disast Med 2004;19(3):191—9.
may remain ill-equipped to respond in the event of a dis-
11. Hsu EB, Thomas TL, Bass EB, Whyne D, Kelen GD, Green
aster, which can have negative outcomes for all involved. GB. Healthcare worker competencies for disaster training.
Therefore, research needs to be coordinated and aimed at BioMed Central (Open Access) 2006;6(19):1—19. Available at:
establishing standards in delivery and content of disaster http://www.biomedcentral.com/1472-6920/6/19. Accessed
preparedness education and training, which may also have a 6/9/07.
positive effect on nurse attitudes in disaster response; creat- 12. Inglesby TV, Grossman R, O’Toole T. A plague on your
ing effective hospital disaster plans; and improving hospital city: observations from TOPOFF. Clin Infect Dis 2001;32:
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ing disaster preparedness into a community health nursing
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Jennings Disaster Nursing Management Model. Nurs Educ Pract
None declared. 2004;4:69—76.
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